Annals for Hospitalists - February 2023
Authors: David H. Wesorick
Journal: Annals of Internal Medicine (2023)

Web ExclusivesFebruary 2023Annals for Hospitalists - February 2023FREEDavid H. Wesorick, MDDavid H. Wesorick, MDFrom Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWHO202302210 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesHow to Treat Poor Sleep in the Hospital—Katrina L. Piggott, MD, MSc, and Christine Soong, MD, MScSleep is an important ingredient in a patient's recovery from illness or injury, but there are many barriers to good sleep in the hospital. In this article, the authors provide an approach to restless inpatients.Highlights of Recent Articles From Annals of Internal MedicineHow Would You Resuscitate This Patient With Septic Shock? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterAnn Intern Med. 2023;176:253-259. Published 14 February 2023. doi:10.7326/M22-3385In this article, 2 discussants provide their answers to the following questions:1. What is the role of lactate levels in guiding resuscitation?2. What is the ideal crystalloid for resuscitation?3. What is the role of intravenous corticosteroids in patients with septic shock and persistent vasopressor needs?Key points for hospitalists include:Elevated blood lactate levels in sepsis often indicate organ hypoperfusion. Therefore, lactate levels can be useful in guiding resuscitation in patients with septic shock. However, lactate levels can increase for reasons other than organ hypoperfusion (for example, liver failure, kidney injury, diabetic ketoacidosis, thiamine deficiency, active malignancy, seizure, and medications) and can lag as a marker of resuscitation, potentially leading to over-administration of fluids. Lactate levels may be most useful when used along with other assessments of volume status and tissue perfusion (for example, capillary refill time, passive leg raise, left ventricular velocity time index, stroke volume variation, and pulse pressure variation).In some studies, balanced crystalloids, compared with normal saline, have been associated with lower rates of acute kidney injury, hyperchloremic metabolic acidosis, and death in patients with sepsis. However, the data comparing balanced crystalloids with normal saline are conflicting and inconsistent. Despite the limitations of the available evidence, there does not seem to be any counterbalancing benefit to using normal saline.Glucocorticoids have been shown to reduce the duration of vasopressor use, without clear survival benefit. They do not seem to significantly increase the rate of bacterial infections, but they are associated with hyperglycemia and hypernatremia. The optimal timing of use remains uncertain.In the Clinic: Chagas DiseaseAnn Intern Med. 2023;176:ITC17-ITC32. Published 14 February 2023. doi:10.7326/AITC202302210This narrative review article discusses the risk factors for and diagnosis and treatment of Chagas disease, one of the most common, yet neglected, parasitic diseases in the United States.Key points for hospitalists include:Chagas disease, caused by infection with Trypanosoma Cruzi, is usually transmitted via exposure to the triatomine bug feces passing through defects in the skin or mucous membranes of hosts. Vector-borne transmission occurs in Mexico and Central and South America and is rare in the United States. Transmission is most likely with prolonged stays in endemic areas. Transmission can also occur vertically or from blood transfusion or organ or bone marrow transplant.Acute disease is usually characterized by fever and lymphadenopathy and typically goes undiagnosed. Untreated, the disease moves into a chronic phase, which remains asymptomatic in most patients, unless they develop cardiac or gastrointestinal manifestations.About 30% of infected patients develop cardiac disease and about 10% develop gastrointestinal disease, usually years or decades after transmission. Cardiac disease can include conduction system abnormalities and cardiomyopathy, and gastrointestinal disease can include esophageal dysmotility and dilation (that is, megaesophagus) or similar effects on the colon (that is, megacolon).Patients presenting with these late-stage findings, in the setting of an appropriate exposure history, should be tested for Chagas disease (serology testing, using 2 or more different serologic tests), and those with positive findings can be referred to an infectious disease specialist for treatment.The Latest Highlights From Journal ClubWhat is the efficacy of vitamin K antagonists (VKA) versus rivaroxaban for vascular outcomes in patients with atrial fibrillation and rheumatic heart disease?In rheumatic heart disease–associated AF, rivaroxaban increased adverse vascular outcomes vs. VKA at 3 yAnn Intern Med. 2023;176:JC2. doi:10.7326/J22-0102This randomized controlled noninferiority trial compared rivaroxaban with VKA in 4565 patients with rheumatic heart disease and atrial fibrillation. The average time free from a stroke or vascular death was significantly longer in the patients treated with warfarin.Does treatment with high-dose glucocorticoids improve dyspnea in patients with cancer?In cancer with dyspnea, high-dose dexamethasone did not improve dyspnea and increased SAEsAnn Intern Med. 2023;176:JC7. doi:10.7326/J22-0106This randomized placebo-controlled trial compared dexamethasone (4 to 8 mg daily) with placebo in ambulatory patients with dyspnea and cancer of any type and found that dyspnea was not improved in the steroid group, but adverse effects requiring hospitalization occurred more frequently.Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: David H. Wesorick, MDAffiliations: From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W.)Disclosures:Author has reported no disclosures of interest. Forms can be viewed at https://rmed.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M22-2807.* The authors contributed equally to the article. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - How to Treat Poor Sleep in the Hospital Katrina L. Piggott and Christine Soong Metrics February 2023Volume 176, Issue 2 ePublished: 21 February 2023 Issue Published: February 2023 Copyright & PermissionsCopyright © 2023 by American College of Physicians. All Rights Reserved.Loading ...